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Achilles tendinopathy

Achilles tendinopathy is pain and swelling in the tissue that connects your calf muscle to your heel bone.

Your Achilles tendon is very strong and flexible. It’s at the back of your ankle and connects your calf muscle to the bone in the heel of your foot (calcaneum). It’s the largest tendon in your body and allows you to run, walk, jump and go up and down stairs.

Achilles tendinopathy (also called Achilles tendonitis) is pain and swelling you can get in your Achilles tendon if you injure or overuse it. It usually happens gradually over a period of time.

Achilles tendinopathy mostly affects people who play sport, particularly runners.

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Image showing the Achilles tendon

Details

  • Symptoms Symptoms of Achilles tendinopathy

    The main symptom of Achilles tendinopathy is pain, usually at the back of your ankle. You may also have some stiffness. The pain is usually worse first thing in the morning, or after you have been inactive for a period of time. Achilles tendinopathy may interfere with your day-to-day life.

    At first you might have pain when you start and after you finish exercise, but the pain goes away when you’re exercising. Over time, as the injury gets worse, you may also have pain while you exercise and it may become constant. You may also have some swelling and your Achilles tendon might feel tender when you touch it.

    If you have any of these symptoms, visit a physiotherapist (a health professional who specialises in maintaining and improving movement and mobility). Alternatively your GP may be able to refer you to a physiotherapist.

    If you have sudden pain in your heel or calf, and it becomes swollen, bruised and painful, you may have completely torn your Achilles tendon. If this happens, you must seek urgent medical attention.

  • Diagnosis Diagnosis of Achilles tendinopathy

    Your GP or physiotherapist will ask you about your symptoms and examine you. He or she may also ask you about your medical history.

    Your GP or physiotherapist may ask you to do a series of movements or exercises to see how well you can move your leg. He or she may also examine your leg, heel and ankle and may squeeze your calf muscle to check the movement of your foot.

    You may need to have further tests to confirm if there are tears in your Achilles tendon, which may include the following.

    • An ultrasound scan. This uses sound waves to produce an image of the inside of your leg. 
    • An MRI scan. This uses magnets and radio waves to produce images of the inside of your leg.

    Your GP or physiotherapist may refer you to see an orthopaedic surgeon (a doctor who specialises in bone surgery), or a sports medicine specialist.

  • Treatment Treatment of Achilles tendinopathy

    The type of treatment you may need for Achilles tendinopathy will depend on how serious your injury is. Your symptoms may take between three and six months to get better (see our frequently asked questions for more information).

    Self-help

    There are a number of things you can do to help Achilles tendinopathy. The main ones are listed below.

    • Reduce the amount of exercise you’re doing and how often you exercise. This will help to rest your tendon. 
    • Wear a small heel raise in each shoe. This will help to reduce the stress on your Achilles tendon. 
    • Wear well-padded and supportive shoes. 
    • Run or exercise on a soft running surface. 
    • Stretch your Achilles tendon every day.

    If the pain or swelling is bad, you can ice the back of your ankle to reduce swelling and bruising. Use an ice pack or ice wrapped in a towel. Don’t apply ice directly to your skin as it can damage it.

    Medicines

    If you need pain relief, you can take over-the-counter painkillers, such as paracetamol or ibuprofen. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.

    Your doctor may also prescribe you glyceryl trinitrate patches to put on the skin on your heel to reduce pain from Achilles tendinopathy.

    Physical therapies

    Your GP may refer you to a physiotherapist, or you can arrange an appointment with a physiotherapist directly yourself.

    Physiotherapy will aim to strengthen and stretch your Achilles tendon. Your physiotherapist will give you a programme that will include stretching exercises and heel-lowering exercises on a step (referred to as eccentric loading). You may need to do these exercises every day.

    Your physiotherapist may use other techniques to help reduce your pain and speed up the healing of your Achilles tendon, such as massage.

    Non-surgical treatments

    If your Achilles tendinopathy doesn’t get better with other treatments, your doctor may recommend that you have extracorporeal shockwave therapy. In this treatment, your doctor will use a machine to pass high energy shockwaves through your skin to the affected area of your tendon. It’s a relatively new treatment and doctors still don’t know how well it works. Ask your doctor for more information.

    There are other specialist treatments that your physiotherapist or sports medicine specialist might recommend too. These include:

    • blood or platelet-rich plasma (PRP) injections, which are thought to help your Achilles tendon heal faster
    • high-volume injections of saline, which are thought to help ease the pain from Achilles tendinopathy

    However, these treatments aren’t widely available and are only used by expert specialists because there isn’t much good evidence to show they work. Ask your physiotherapist or sports medicine specialist for more information.

    Surgery

    Your doctor may recommend surgery if, after around six months, other treatments haven’t worked and your symptoms are having an impact on your day-to-day life.

    Surgery involves removing damaged areas of your tendon and repairing them.

    Bupa On Demand: Musculoskeletal services

    Want to talk to a Bupa consultant about muscle and bone treatment? We’ll aim to get you seen the next day. Prices from £250.

  • Achilles tendonitis treatment on demand

    You can access a range of our health and wellbeing services on a pay-as-you-go basis, including achilles tendonitis treatment.

  • Causes Causes of Achilles tendinopathy

    Achilles tendinopathy is a common injury in runners and people who play sports that involve running.

    It’s usually caused by overusing your Achilles tendon. As you get older, your Achilles tendon becomes less flexible and less able to cope with the stress that running puts on it. Very small tears can start to develop and if you carry on running, the tears won’t heal and your tendon can become weaker. Sometimes your Achilles tendon can tear completely and this is called Achilles tendon rupture.

    Achilles tendinopathy is more likely to develop if you:

    • have a family history of the condition
    • have a health condition such as diabetes or high blood pressure
    • take a type of antibiotic medicine called quinolone
    • have a high or low arched foot
    • start a new physical activity, or increase your intensity of exercise – for example, how far and how fast you run
    • train on hard, slippery or slanting surfaces
    • change the shoes you wear, or wear the wrong type of shoes
    • have a poor running technique, for example, you roll your feet inwards as you run, which is called overpronation
    • wear high heels frequently
    • have your saddle set too low when you cycle
  • Prevention Prevention of Achilles tendinopathy

    There are a number of things you can do to help prevent Achilles tendinopathy. The main ones are listed below.

    • Wear appropriate and well-fitting shoes when you exercise. 
    • When you start a new exercise regime, gradually increase the intensity and the length of time you spend being active. 
    • Warm up your muscles before you exercise and cool them down after you have finished. The benefit of stretching before or after exercise is unproven. However, it may help to stretch your calf muscles, which will help to lengthen your Achilles tendon, before you exercise. 
    • If the shape of your foot increases the stress on your Achilles tendon, wear an insole in your shoe. You can buy these off-the-shelf or they can be custom-made for you. Ask your physiotherapist for advice.
  • FAQs FAQs

    How long will Achilles tendinopathy take to heal?

    Answer

    Once you get treatment, it can take between three and six months for the symptoms of Achilles tendinopathy to get better. If it doesn’t heal after this time, you may need to consider having surgery.

    Explanation

    Your symptoms should get better three to six months after you start treatment. If they don’t, your GP may refer you to see an orthopaedic surgeon or sports medicine doctor. Surgery may be an option but it's usually a last resort after you have tried other types of treatment.

    The sooner you're diagnosed with Achilles tendinopathy and start your treatment, the more effective it will be. If you do too much exercise while you’re having treatment, it may delay your recovery.

    Will I be able to return to activity after treatment for Achilles tendinopathy?

    Answer

    Most people with Achilles tendinopathy will be able to return to running and playing sport after treatment. However, it's important that you return to physical activity gradually.

    Explanation

    If you need an operation to repair your tendon, you may not be able to return to the level of activity you were doing before. This is because the tendon may not be strong or flexible enough for you to run and play sport.

    When you go back to running or playing sport there are a number of things you can do to reduce the risk of further injury. The main ones are listed below.

    • If your Achilles tendinopathy was caused by an underlying problem, it’s important to correct this before you start activity again. For example, if you roll your feet inwards as you run, you may need to wear insoles in your shoes. Or you may need to visit a podiatrist (a health professional who specialises in conditions that affect the feet) to have your gait analysed. Your gait is the way you walk. 
    • Prepare a training programme and start any new activity slowly and gradually build up your activity levels. Make sure you have rest days. If your symptoms don’t return, you can build up to more intensive activity. 
    • Stretch after any activity and continue with any muscle strengthening exercises you have been given by your physiotherapist.

    What type of shoe should I be wearing?

    Answer

    Wearing the right type of shoe for the activity you’re doing can help to prevent Achilles tendinopathy from developing or coming back after an injury. Wearing insoles or heel lifts in your shoes can help to reduce pain from Achilles tendinopathy.

    Explanation

    Running or playing sports can put a lot of strain on your feet and your Achilles tendon, so it’s important to wear the right shoes.

    The type of shoe that you need will depend on things like how you run and the kind of activity you’re doing. For example, shoes for running should be flexible so that your feet can bend and flex through each step. Shoes for racquet sports, in contrast, need to be stiffer. Go to a good sports or running shop and have your feet properly fitted for the shoes you need for your sport.

    Wearing high heels can put strain on your Achilles tendon. Try not to wear high heels often and stretch your calf muscles regularly.

    If you have Achilles tendinopathy, you may be able to reduce any pain by wearing insoles or heel lifts in your shoes. Custom-made insoles can help to correct the shape of your feet and put less strain on your Achilles tendon. Your GP or physiotherapist can refer you to podiatrist to have these made. Heel lifts raise your feet by a small amount. This takes some strain off the tendon and moves your heel away from the back of your shoe, where rubbing can occur.

    Shoes that are softer at the back of the heel can reduce irritation of your Achilles tendon and help to reduce your pain. It’s also important to regularly stretch your Achilles tendon every day.

  • Resources Resources

    Further information

    Sources

    • Asplund CA, Best TM. Achilles tendon disorders. BMJ 2013; 346:f1262. doi:org/10.1136/bmj.f1262
    • Achilles tendinopathy. NICE Clinical Knowledge Summaries. cks.nice.org.uk, published April 2010
    • Achilles tendon. British Orthopaedic Foot and Ankle Society. www.bofas.org.uk, published 27 February 2014
    • Carcia CR, Martin RL, Houck J, et al. Orthopaedic section of the American Physical Therapy Association. Achilles pain, stiffness, and muscle power deficits: achilles tendinitis. J Orthop Sports Phys Ther 2010; 40(9):A1–26. www.guideline.gov 
    • Achilles tendonitis and rupture. PatientPlus. www.patient.co.uk/patientplus.asp, published 7 June 2013
    • Achilles tendinitis. American Academy of Orthopaedic Surgeons. www.orthoinfo.aaos.org, published June 2010
    • Achilles tendonitis. Medscape. www.emedicine.medscape.com, published 19 July 2013
    • Platelet-rich plasma injection for achilles tendinopathy. California Technology Assessment Forum. www.ctaf.org, published 13 October 2010
    • Weinfeld SB. Achilles tendon disorders. Med Clin N Am 2014; 98(2):331–38. doi:10.1016/j.mcna.2013.11.005
    • Wilson F, Bleakley C, Bennett K, et al. Exercise, orthoses and splinting for treating Achilles tendinopathy (protocol). Cochrane Database of Systematic Reviews 2013, Issue 12. doi:10.1002/14651858.CD010874
    • Extracorporeal shockwave therapy for refractory Achilles tendinopathy. National Institute for Health and Care Excellence (NICE), August 2009. www.nice.org.uk 
    • Maffulli N, Spiezia F, Longo UG, et al. High volume image guided injections for the management of chronic tendinopathy of the main body of the Achilles tendon. Phys Ther Sport 2013; 14(3):163–67. doi:10.1016/j.ptsp.2012.07.002
    • Herbert RD, de Noronha M, Kamper SJ. Stretching to prevent or reduce muscle soreness after exercise. Cochrane Database of Systematic Reviews 2011, Issue 7. doi:10.1002/14651858.CD004577.pub3
    • Abnormal gait. PatientPlus. www.patient.co.uk/patientplus.asp, published 17 September 2010
    • Racquet sports. The College of Podiatry. www.scpod.org, accessed 6 March 2014
    • Running. The College of Podiatry. www.scpod.org, accessed 6 March 2014
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